Opioid Overdose Emergency Response Course Goal This program is

Opioid Overdose Emergency Response Course Goal This program is designed to train emergency responders and others who may respond to an opioid overdose, including use of Naloxone (Narcan). 1

Course Objectives After completing this course, you will better be able to: 1. Describe opioid characteristics and the opioid epidemic 2. Perform initial actions, including donning of PPE, required for a response to a potential opioid overdose 3. Identify how to use Naloxone (Narcan) 4. Administer Naloxone (Narcan) during an overdose response 2

Acknowledgement The Midwest Consortium for Hazardous Waste Worker Training adapted this program from work created by ERS International for private industry under cooperative agreement number U45 ES 06184 from the National Institute of Environmental Health Sciences (NIEHS), as well as programming created by NIEHS. 3

CAUTION CAUTION! Personnel must be trained to their employer’s site-specific policies and procedures. 4

Course Modules 1. Opioids 2. Initial Actions 3. Treatment (Narcan) 5

Module 1: Opioids What Is an Opioid? A class of drugs used to reduce pain. Prescription opioids are prescribed to treat moderate to severe pain, but have serious risks and side effects. Examples: oxycodone, hydrocodone, morphine, methadone, and fentanyl. Illegal opioid: heroin, illegally produced fentanyl and other synthetic opioids. 6

What Is Fentanyl? A powerful synthetic opioid, similar to morphine and heroin. 50 to 100 times more potent than morphine. A rapid-acting synthetic opioid that alleviates pain. Acts quickly to depress central nervous system and respiratory function. Exposure may be fatal. 7

What Color Is Fentanyl? Fentanyl powder may be: White Pink Purple Blue Green The color and texture do not provide any indication about its strength 8

How Much Fentanyl Is Fatal? 2‐3 milligrams of fentanyl can induce respiratory depression, arrest, and death. Comparable to 5-7 grains of salt! 9

Legal Forms of Fentanyl and Synthetic Opioids What do they look like? Lozenges called “lollipops” Tablets Sprays Patches Injectables 10

Photos of Illegal Fentanyl 11

Background on the Epidemic Drug overdoses killed 70,630 in the U.S. in 2019. Leading cause of death for Americans under 50. Opioids were involved in 49,860 overdose deaths in 2019. Other synthetic opioids (primarily fentanyl) overdose deaths increased nearly 14-fold from 2012 to 2019. Lethal doses of heroin, fentanyl, and carfentanil. (U.S. DEA photo) 12

National Drug-Involved Overdose Deaths* Number Among All Ages, 1999-2019 13

Recovery is Possible Support Family Community Peers Recovery Coach Mutual aid groups Assistance Programs Medication-Assisted Treatment (MAT)

Module 2: Initial Actions Module Content A. Notification B. Isolation C.Protection D.Identification 15

Module 2: Initial Actions A. Notification If you are the First Responder on the scene, you should give the Brief Initial Report and assume command as soon as possible from a safe distance. Brief Initial Report 1. Your Name 2. Incident Location/Approach 3. Type of Incident 4. Critical Info (Hazards, Injuries, Symptoms) 5. What help do you need? 6. Command Post Location 16

Assign an Initial Actions Supervisor and Medical Supervisor as early as personnel resources allow. This allows for the safest and most effective control at the scene. 17

Module 2: Initial Actions B. Isolation The Incident Commander or Initial Actions Supervisor should confirm the following with regards to isolating the incident scene: Create and maintain a minimum Hot Zone around the patient(s) of 6 feet with visible markers Isolate/evacuate bystanders away from the patient Report any information gathered to the Incident Commander including the patient’s condition 18

Module 2: Initial Actions C. Protection 19

What Are the Routes of Exposure? Inhalation of powders and aerosols Skin, eye, and mucous membrane absorption Incidental ingestion (hand to mouth) Accidental inoculation with sharps or needles Leading science organizations advise that incidental skin contact with dry products is not likely to cause overdoses. Skin contact with liquid or gel can be highly toxic. 20

Skin Exposure Skin exposure to powdered or dry forms of fentanyl is not likely to cause overdose in small amounts if promptly removed. Liquid or highly concentrated fentanyl can be absorbed rapidly via skin and can be extremely toxic. It is prudent to provide full skin protection because the fatal dose is so low. 21

IAB Recommended Best Practices for Minimal Risk Exposure Risk Operational Functions Minimum Recommended PPE Minimal (no visible product or product contained within syringe or other package) Response to a Standard duty uniform person with and nitrile suspected gloves (NFPA 1999) overdose 22

IAB Recommended Best Practices for Moderate Risk Exposure Risk Operational Functions Moderate (small Response to one or volume [grams] more persons with of material suspected overdose; visible and not response to a contained within localized seizure a package) Minimum Recommended PPE Standard duty uniform; nitrile gloves (NFPA 1999); P100 filtering facepiece respirator; safety glasses Note: While the IAB recommends a P100 filtering facepiece respirator, N100 and R100 filtering facepiece respirators should work acceptably too. 23

NIOSH Standard Operating Procedures to protect responders Hazard assessment No drinking, eating, smoking at the scene Do not touch eyes, nose, mouth Always wear nitrile gloves when illicit drugs may be present Field testing of possible drug residue is NOT recommended Avoid tasks that aerosolize suspected fentanyl Wash hands with soap and water 24

Decon Direct skin contact with suspected fentanyl should be immediately washed with soap and water. Do NOT Use alcohol-based hand disinfectants or hypochlorite bleach solutions as they may enhance skin absorption of fentanyl. 25

Decon Avoid contamination while removing PPE. Isolate used PPE for decon or disposal. Decon surfaces with absorbent wipes, and a peracetic acid (5%) or hydrogen peroxide-based (10%) solution. 26

Module 2: Initial Actions D. Identification Overdose may result in: Stupor Pinpoint pupils that later may become dilated Cold and clammy skin Cyanosis: blue or purplish discoloration due to low oxygen Coma Respiratory failure leading to death The presence of these 3 symptoms is strongly suggestive of opioid poisoning: 1. Coma 2. Pinpoint pupils 3. Respiratory depression 27

Identification Opioid-associated resuscitative emergencies are defined by the presence of cardiac arrest; respiratory arrest; or severe life-threatening instability. The American Heart Association recognizes the difficulty in accurately differentiating opioid-associated resuscitative emergencies from other causes of cardiac and respiratory arrest. Other factors to consider include patient history, evidence on scene, and bystander reports. 28

Module 3: Treatment 29

AHA flow chart for non-Healthcare Providers 30

AHA flow chart for Healthcare Providers 31

Key Actions to Remember 1. Identify and assess the victim for responsiveness. 2. If victim is not responsive and not breathing, initiate CPR and AED per protocol: Check for pinpoint pupils. If suspected opioid overdose call for Narcan. 3. Check for medical alert tags (around wrists, ankles, or neck) indicating a preexisting medical condition. 4. If respirations are present and the victim is unconscious, assess breathing status, pupils, and pulse. If breathing is adequate ( 8 per minute, no cyanosis) and no signs of trauma, place in the recovery position. Check for pinpoint pupils. If breathing is than 8 per minute or signs of low oxygen and overdose is suspected (based on history, evidence on scene, bystander reports, patient assessment) proceed with Naloxone administration and high O2 therapy. 32

Naloxone (Narcan) Naloxone (Narcan) displaces the opioid from the receptors in the brain. Can rapidly reverse respiratory depression in a patient with an opioidassociated emergency. Naloxone doesn’t work with drugs other than opioids. Naloxone is safe and effective. It is not a controlled substance and has no abuse potential. 33

Naloxone (Narcan) Multiple doses are sometimes required. If the person does not wake up in five minutes, a second dose should be administered It is available as an injectable and nasal spray Automatic injectors are similar to an EpiPen Multi-step or single-step sprays are packaged containing two doses to allow for repeat dosing if needed 34

State Laws Vary on Naloxone Naloxone is accessible in all states without a prescription. All states have Naloxone Access laws, which protect individuals who administer Naloxone Only Kansas, Texas and Wyoming DO NOT have Good Samaritan laws, which protect individuals who call for medical assistance for an overdose victim These laws are all different. Check your state’s law for more info: https://www.gao.gov/products/gao-21-248. 35

Treatment of Opioid Overdose Emergency with Single Step Nasal Spray 1. Retrieve Naloxone Kit. 2. PRIOR to administration of Naloxone, ensure safety of the victim and remove any sharp or heavy objects within victims reach. The sudden onset of opioid withdrawal may cause physical symptoms, such as agitation, rapid heart rate, nausea, projectile vomiting, violent behavior, seizures, difficulty breathing. 3. Administer 4 mg of Naloxone in one nostril. (do not prime nasal spray) 4. If no response after 3-5 minutes and there is an available second dose of Naloxone, repeat the administration. Continue CPR including rescue breathing, (if initiated prior to Narcan) until respirations return Continue to monitor respirations and pulse if patient was placed in recovery position with high flow oxygen Transport to local Emergency Department via EMS. 36

Opioid Overdose Response Exercise 1. Review the purpose of the Exercise. 2. Read the directions on the checklist. 3. Review the signs and symptoms of an opioid overdose. 4. Each participant will follow the skills checklist to assess and treat an overdose incident. 5. Each participant will practice the skill until they have mastered all the steps on the skills checklist. 37

Summary Opioids/Fentanyl and the related epidemic Recommended PPE during an opioid response Assessment of suspected opioid overdose Use of Naloxone (Narcan) during an opioid response 38

Resources IEHS Worker Training Program N https://tools.niehs.nih.gov/wetp/index.cfm?id 2587 Centers for Disease Control and Prevention (CDC) https://www.cdc.gov/niosh/topics/fentanyl/risk.html InterAgency Board for Emergency Preparedness & Response (IAB) https://www.interagencyboard.org/sites/default/files/publications/IAB%20First%20R esponder%20PPE%20and%20Decontamination%20Recommendations%20for%2 0Fentanyl.pdf U.S. Drug Enforcement Administration (DEA) https://www.dea.gov/documents/2017/2017-11/2017-11-28/fentanyl-safety-recomm endations-first-responders 39